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At least hospital administrators pay attention to how much things cost.
In many cases, doctors literally do not know how much the treatments they provide cost. This means that they simply don’t do any cost-benefit analysis. They will prescribe an expensive brand-name drug instead of a generic drug that does basically the same thing for no reason other than because they heard about it more recently.
Why is it the physicians job to know what things cost? A hospital will literally have hundreds of employees whose full-time job it is to figure out what things cost and deal with insurance companies, who are always changing things constantly. Even a small practice will usually have 2-3 employees minimum who spend most of their day figuring that stuff out.
It's entirely orthogonal to providing good medical care.
We do cost benefit analysis all the time, but it is in terms of the risks and benefits of a given intervention, wouldn't you rather us be focusing on that?
If you're not capable of doing it, then you need to figure out a workflow so that someone who is capable provides a price. This is a part of basically every other service in every other industry; it is not impossible.
To go to the auto shop example, you could equally imagine a mechanic-head praising the beauty and sanctity of the Art of
MotorcycleAutomotive Maintenance, and how carefully he considers the non-monetary risks/benefits of a given intervention, saying that in his view, the price is entirely orthogonal to providing good automotive care. He could be so educated and experienced that he thinks it would be an utter waste of his time to even put together estimates. I would say that perhaps he is right on all those points. I still want a price. I want it as a routine matter. Maybe he will have some customers who literally don't care, who have a unique, historical vehicle and a fat bank account, and they just want the artistic approach, damn the costs. But as a routine matter, I don't care how beautiful you think your orthogonal things are; you are running a service business where the customer needs to know the costs/benefits. It is doubly important in the medical domain for them to be informed of the costs/benefits if they're going to give informed consent.If you need to structure your workflow so that a different employee is up front assembling the estimate while the genius mechanic is spending every minute of his time on his craft, so be it. You have people that do that stuff anyway. Do it up front, not after-the-fact. Keep your patient informed. Just give him the damn price.
There are multiple parallel problems here.
The cost is fundamentally unknown. It is reasonable to determine what the average cost of a thing is, but that is not helpful information because when we leave the average the costs can become profoundly immense. More people are upset with an estimate that is off by multiple orders of magnitude than by no estimate at all, and that will happen.
To torture your mechanic analogy, it's like if you go to buy a car and ask for a Corolla, but 5% of the time you get a Bentley whether you want it or not.
The average cost is not necessarily known to your doctor. If I'm your surgeon I know what my professional fees are and how long my average case takes. I probably know the billing codes used, if I'm business minded I may know something about the average cost of supplies, instruments, and equipment. However a run of the mill routine surgery requires a team of 40+ people between the office visit, PAT, pre-op, intra-op, PACU, and post-op. It is unbelievable how many hands are involved and it is incredibly difficult to keep track. You immediately start running into problems like "cleaning staff are a critical part of the OR and are a cost to the hospital but are not usually considered a part of the surgery, is that a cost or is it not a cost?" or "does this facility charge by the minute for anesthetic gases or use a flat fee" both options are viable, your anesthesiologist probably knows, your surgeon probably doesn't. Keep track of "costs" is a full time job with an entire department just for the OR. Your surgeon might be able to say "your surgery probably costs 10k" because they asked someone in a billing meeting what all the averages on the spreadsheets said, but nobody wants to have a 20 minute conversation about how much of an oversimplification that is.
Additionally that is fundamentally not the surgeons job and does nothing to improve the surgeons provision of medical care. We evaluate whether to perform a case or not based off of the medical risks and benefits, not the cost. This is part of why healthcare is expensive in the U.S. but most people prefer that to the alternative.
Doctors wear a lot of hats. Things like increased regulatory burden and the dance with insurance below mean that you have of multiple departments involved in figuring out how to deal with the above. We already do a lot of things like that slow us down and prevent us from actually spending time with patients. Making it worse is not desirable to us or our patients.
The cost is irrelevant, which disincentivizes processes involved in streamlining all these things and makes it useless for your doctor to know and be able to relay to you. Almost all procedures are paid for by insurance or involuntary charity care by the hospital, with a small rarity of actual self-pay. Getting insurance to pay for something involves complicated negotiations where they try and pay you less than "cost" so you exaggerate cost as much as possible in hopes you don't actually lose money. It is not uncommon for the payment mix to end up being something like medicaid reimbursing 80% of cost, medicare 85% and private insurance 110%. If you mostly care for medicare and medicaid patients you go out of business (which has happened a lot lately) or require government bailouts. This is why the sticker price is so insane, and hospitals will almost always drop 90% of the bill if you end up being cash pay. You have to negotiate with the insurance company and that involves the "official cost" of a gallbladder removal being 100k instead of 5k or whatever.
A surgery has more in common with a government procurement and bidding process than getting a car repaired.
Even more simple things like an office visit are a pain in the ass to figure out. Unless you are doing very specific types of PCP practice or outpatient cash Psychiatry you are taking insurance. Therefore I don't know what the visit costs. I know what my billing team will try and charge for my time, they'll use the specific office visit billing code, I'm told to make sure to put X and Y thing in my note so they actually cover the work I did, but then I know that even the insurance company is supposed to pay for that code they'll make a big stink about it and require hours of the billing teams time going back and forth to make sure that its not worth it to actually get paid for that, even though the other insurance company always takes it if I put in X and Y, so my office staff will adjust the coding and bill you for the down coded visit even though that's not what I did and that's somewhat illegal, and your sister will get billed the actual billing code because she has "better" insurance.
All kinds of asinine shit like that happens for the most routine interaction with healthcare.
This is why psychiatrists are like "dude just pay me 100 an hour and we are good" and why there are now multiple forms of primary care that avoid working with insurance.
"What's my rate for a visit" is never a viable question because every insurance company pays me differently and its constantly changing year to year and I'm effectively only paid for by insurance.
This is false, as we've already discussed.
I don't care whose job it is. Every single other industry has figured out how to do this basic business practice in a decent way, and many times, there is division of labor.
This is the most pernicious, absolutely atrocious lie that is the core reason we have such a disaster of a medical industry. You cannot believe that anyone will read this entire thread branching from the OP and think that this a remotely reasonable response. Sure, if we just accept that everything is broken with insane prices that don't mean anything, then nothing means anything and we're doomed to dysfunction. We can do better.
"Your surgery will cost anything between 4,000 and 5 million dollars, as those are the minimum and maximum recorded prices we have charged in the last ten years." Is not a satisfactory answer. "The median price for the surgery is 5,000 dollars" is not viable either because patients will sue if it's wildly off that. Either way the cost doesn't matter, it's almost entirely removed from how much the hospital gets paid or collects.
This like a governmental procurement process. The person who has knowledge of everything is the head of the OR or billing department, not the person who is on the ground doing the thing. You can't have the head of the FBI come down every time and explain what the cost of an investigation is, the individual agents sure as hell don't know, why would they need to?
Healthcare systems (including doctors) are the victims here, victims of a predatory insurance industry and unhelpful overregulation that needs to be replaced with functional regulation or needs to be understood to be reducing the amount of and increasing the price of care. Don't blame us doctors and nurses are leaving the field and hospitals are shutting down because insurance companies are winning the battle. Blaming us helps them collapse the system faster.
C'mon man, you did better in the linked comment. You already gave a vastly better answer. Did you forget what you said yesterday?
You cannot seriously think that every other industry that has solved this problem requires the head of their billing department to generate every price. How do you think other industries solve this problem?
I'm not blaming you. I'm just asking you to do basic business practices in a decent way, just like how everyone else does. You can do this. You really can.
I'm confused as to how you see his earlier estimate as better at all, much less vastly better. Are you saying you'd be happy with a price tag which consists of the range $4000 to $1500000?
The chance of hitting the $1.5m upper end makes this price tag functionally identical to "idk, could be anything" for most people. Unless you have millions in assets then 1.5 million is already enough to ruin your life and put you in a place where you're probably staring down bankruptcy. Whether the cost caps out at 1.5 million or 1.5 billion is irrelevant to people who can pay neither of those numbers.
The important point is the conceptual realization that patients cannot consent without being informed. It's called informed consent. Part of being informed is being informed about the costs. Obviously, there is going to be a knowledge gap both in terms of the medical and financial costs/benefits. When it comes to medical cost/benefits, people mostly acknowledge the knowledge gap and say that it's important for doctors to find a way to explain the situation as they can to the patient. There is obviously a range of quality here, but the answer is that you have to try. When it comes to the financial side, they instead just say that it's impossible. They give up. They don't even try. (It's just a coincidence that doing this is in their interest.)
His prior answer gave a probability attached to a known unknown, conveying the information known by the doctor in a way that is very representative of the doctor's knowledge. First, it is obvious that they can do this sort of thing.
Second, as to the question of comparing the quality of the answers, suppose you were considering playing a lottery-style game. One just told you, "The range of payouts is between $5k and $1.5M." A second told you, "The payout is about $5k with about probability p, and the payout is about $1.5M with probability 1-p." Which of these answers do you think is better quality information? Which of these answers do you think is more helpful in analyzing whether you would like to play?
Third, the lingering question is whether/when it matters. It will obviously depend. It will depend on the dollar figures; it will depend on the probabilities; it can also obviously depend on how the individual's personal insurance is structured (common factors would be deductible, co-insurance, and out-of-pocket max). From there, we have a several-dimensional parameter sweep. We could sit down and generate plots. I'm sure we would see tons of regimes where having the information is basically useless. But I'm also confident that we would see tons of regimes where having the information is useful. I'm sure the good doctor we are talking to can come up with plenty of individual examples off the top of his head that are in the regime where it doesn't matter. Don't care. There are almost certainly also plenty of examples where it does matter; I would venture to guess that, actually, for the vast majority of regular, routine decisions, it can, in fact, matter. The standard party line is to just not even try, in any case, because there might be other cases where it doesn't matter. That's absurd. Moreover, it betrays a lack of understanding of economic thinking. There are always non-marginal cases. In no other area of economics do we say, "There are some extremely high/low value producers/consumers, and since their behavior won't be changed by [alteration to the price system], we should just completely blow up the price system and abandon it." Economists push back on this shoddy reasoning constantly. Sure, there might be someone who just loves eating exactly one apple every day so much that even if we blow up and get rid of the price system for apples, just don't tell anyone how much apples cost, and have them paid for via some complicated mechanism, they'll still buy exactly seven apples every week. Who cares? The price system is there for all of the other cases.
The challenge to someone saying that we should never talk about prices because they never matter is to actually show that they never matter, not that there are some cases in which they might not matter. I think they probably do matter to a hell of a lot more cases than they're willing to admit.
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